Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 33 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
18D
11E
2F
Potential for minimal harm
0A
2B
0C
February 11, 2026Standard inspection · 9 citations
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) program with documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities. Specifically, the facility failed to develop and implement appropriate plans of action for resident concerns regarding food temperatures.
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility's Infection Preventionist failed to attend three of three QAPI meetings reviewed.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on review of Resident Council Minutes, a resident group meeting, and interviews, the facility failed to ensure grievances/complaints brought forward from the Resident Council were addressed and resolved in a timely manner to ensure the residents felt their concerns were acted upon and included the facility response to the group.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interviews and record review, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for one Resident (#5), out of a total sample of 34 residents. Specifically, the facility failed to ensure resident specific, individualized care plans were developed to address the medical, physical, mental and psychosocial needs of a residents identified with a history of suicidal ideation/attempt/gestures.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and interview, the facility failed to ensure residents received food at appetizing temperatures for two of two test trays completed.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure food items were properly dated and stored in 3 of 7 kitchenette refrigerators.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation and interview, the facility failed to provide an ongoing program of individual and group activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of residents on one (Kensington 2 unit) of seven nursing units. Specifically, the facility failed to ensure staff provided a meaningful and engaging activity program, including materials for self-directed activity, for residents residing on the Kensington 2 unit (secured).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to maintain a safe environment, free of accident hazards for one Resident (#74), out of 35 sampled residents. Specifically, the facility failed to ensure Resident #74's smoking materials were stored securely, and a smoking assessment was completed.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored in accordance with acceptable standards for one Resident (#94), out of a total sample of 35 residents. Specifically, the facility failed to ensure Resident #94's three inhaler medications were stored securely.
December 2, 2025Complaint inspection · 2 citations
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on records reviewed and interviews for two of three sampled residents (Resident #2 and #3), the Facility failed to ensure that upon admission, they developed and implemented baseline care plans with interventions, treatments, goals, and outcomes that addressed the residents' overall immediate care needs.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #2), whose Hospital Discharge Summary included instructions related to voiding trials and the removal of his/her indwelling catheter (flexible tube inserted into the bladder to drain urine), the Facility failed to ensure he/she underwent a voiding trial and was assessed timely for potential removal of the catheter, which resulted in the extended use of an indwelling device.
November 15, 2024Standard inspection · 6 citations
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to ensure a reasonable accommodation was made for seven Residents (#150, #101, #49, #148, #65, #102, and #93), on the Sunshine Unit with a census of 35. Specifically, the facility failed to ensure the call system was accessible to the Residents to call for staff assistance.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview, the facility failed to ensure the residents' environment was clean, comfortable, and homelike. Specifically, the facility failed to ensure the resident rooms were maintained in good repair (without holes, painted) and homelike on one unit (K2) out of seven.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure thickened beverage items were properly dated and stored in three of seven kitchenettes.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one Resident (#67) was provided a therapeutic diet as ordered, in a total sample of 34 residents. Specifically, Resident #67, with weight loss, was not provided fortified food as ordered.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on interview and record review, the facility failed to assess triggers for a Resident (#22) with a history of trauma, to avoid potential re-traumatization, out of a total sample of 34 residents.
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that for two Residents (#86 and #232), of a total sample of 34 residents, that Minimum Data Set (MDS) assessments accurately reflected the residents' status.
November 20, 2023Complaint inspection · 3 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on records reviewed and interviews, for one of three sampled Residents (Resident #1), who experienced a decline in condition with weakness, and who had a new physicians order in effect on 4/24/23 at the start of the evening shift, for nursing obtain a urine sample STAT (obtain sample immediately) for testing, the Facility failed to ensure nursing notified the provider when 24 hours later, they had been unable to obtain the sample.
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had a physicians order for STAT (to be obtained immediately) bloodwork, the Facility failed to ensure abnormal laboratory results were promptly reported to his/her Health Care Providers (Physician or Nurse Practitioner (NP). On 04/24/23 Resident #1's laboratory results were reported to the Facility by the laboratory via their electronic medical record system, Point Click Care (PCC), however the results were not reported to his/her Health Care Provider until the following day. Findings Include: Review of the Facility's Policy, titled Lab and Diagnostic Test Results - Clinical Protocol, dated as revised October 2022, indicated the following: -the physician will order lab testing, the staff will arrange for the tests and the laboratory will report test results to the facility; [...]
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had lost his/her upper dentures in October 2022, the Facility failed to ensure he/she had a timely dental consultation for the replacement of his/her upper dentures. Resident #1 was not seen by the dentist until July 2023 for the fabrication of the upper dentures, nine months after the loss of his/her upper dentures. Findings Include: Review of the Facility's Policy, titled Dental Services, dated May 2023, indicated the following: -routine and emergency dental services are available to meet the resident's oral health services; -facility will contract with a Consultant Dentist to provide services on site; -dentures will be protected from loss or damage, to the extent practicable, while being stored; -if dentures are lost, residents will be referred for dental services within three days; [...]
August 3, 2023Standard inspection · 13 citations
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to report alleged incidents for three Residents (#147, #26, and #21), out of a sample of 35 residents. Specifically, the facility failed: 1. For Resident #147, to report a resident-to-resident altercation; 2. For Resident #26, to report an incident of alleged abuse to the state agency in a timely manner; and 3. For Resident #21, to report a resident-to-resident altercation.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, record review, policy review, and staff interviews, the facility failed to ensure that it was free of a medication error rate of 5 percent or greater. The surveyor observed 1 of 2 licensed nurses (Nurse #2) make errors while administering medications on 1 of 2 units. Five medication errors were observed out of 30 opportunities, resulting in a medication error rate of 16.67%. This affected two Residents (#48, #96), out of a total of three residents observed.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview, policy review, and record review, the facility failed to ensure residents were free of significant medication errors for two Residents (#116, #38), out of a total sample of 35 residents. Specifically, the facility failed: 1. For Resident #116, to ensure Eliquis (apixaban) (an anticoagulant medication used to treat and prevent blood clots) was given as ordered following a hospitalization for deep vein thrombosis (DVT) (a blood clot in a deep vein) and pulmonary embolism (a blood clot in the lung) requiring a thrombectomy (a procedure to remove blood clots); and 2. For Resident #38, to ensure Chlorpromazine (an antipsychotic medication used to treat schizoaffective disorder), was given timely per facility policy on 23 out of 42 opportunities, resulting in a significant medication error.
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure medications were dated once opened, according to manufacturer's guidelines in 3 out of 4 medication carts observed.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure one Resident's (#38) grievances were addressed, out of 35 sampled residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interviews, policy review, and record review, the facility failed to apply a splint as ordered by the physician for one Resident (#5), out of a sample of 35 residents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to obtain physician's orders for treatment of a skin tear (layers of skin separate or peel back) for one Resident (#154), out of a total sample of 35 residents.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident (#116), out of a total sample of 35 residents, received proper treatment to maintain vision following cataract surgery. Specifically, the facility failed to ensure follow-up appointments were scheduled with the surgeon following the procedure.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, policy review, and interviews, the facility failed to provide respiratory care per the physician's orders for two Residents (#148 and #5), out of a sample of 35 residents. Specifically, the facility failed for Residents #148 and #5 to clean the oxygen filters as ordered.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on record review, policy review, and interviews, the facility failed to implement trauma informed care plans, specific to Post Traumatic Stress Disorder (PTSD), for two Residents (#40 and #95), out of a sample of 35 residents.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, record review, policy review, and interviews, the facility failed to maintain an accurate medical record for one Resident (#148), out of a sample of 35 residents. Specifically, the facility failed to transcribe a physician's telephone order for the Resident to receive Oxygen.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of infections for one Resident (#116), out of a total sample of 35 residents. Specifically, the facility failed to: a. Ensure contact precautions were maintained for Resident #116 while being treated for an active multi-drug resistant organism per facility policy, and b. Ensure enhanced barrier precautions were maintained for Resident #116 following the identification of a multi-drug resistant organism per facility policy.
- B
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and interview, the facility failed to inform 2 out of 3 Residents, or their representative, of potential liability for payment for non-covered services including estimated cost of services.
Fire safety inspections
23 fire safety citations on file: 7 on February 11, 2026, 14 on November 15, 2024, 2 on August 3, 2023.
Every fire safety citation23 citations
- F
Use approved construction type or materials.
K 161 · February 11, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 11, 2026 · Corrected (the home has a date of correction)
- F
Install properly constructed and protected linen or trash chutes.
K 541 · February 11, 2026 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · February 11, 2026 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · February 11, 2026 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · February 11, 2026 · Corrected (the home has a date of correction)
- C
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 11, 2026 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · November 15, 2024 · Corrected (the home has a date of correction)
- D
Include a process for Emergency Preparedness collaboration.
E 9 · November 15, 2024 · Corrected (the home has a date of correction)
- D
Address subsistence needs for staff and patients.
E 15 · November 15, 2024 · Corrected (the home has a date of correction)
- D
Establish roles under a Waiver declared by secretary.
E 26 · November 15, 2024 · Corrected (the home has a date of correction)
- D
Provide primary/alternate means for communication.
E 32 · November 15, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 15, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · November 15, 2024 · Corrected (the home has a date of correction)
- D
Install properly constructed and protected linen or trash chutes.
K 541 · November 15, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · November 15, 2024 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 15, 2024 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · August 3, 2023 · Corrected (the home has a date of correction)
- C
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 3, 2023 · Corrected (the home has a date of correction)